Quality and Innovation Centers: Kaiser...

12/11/2012

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Quality and Innovation Centers: Kaiser PermanenteBy: Alide Chase, senior vice president Medicare Clinical Operations and Population Care

And

Lisa Schilling, RN MPH vice president Healthcare Performance Improvement

Care Management Institute

M14These presenters have

nothing to disclose.

December 10, 2012

8:30am – 12:00 pm

2

Our Numbers

� 8 regions serving 9 states and the District of Columbia� 8.9 million members (as of 2/11)� 15,000 physicians � 164,000 employees (including 45,000 nurses)� 37 medical centers (with hospitals)� 454 medical offices (ambulatory care buildings)� $44 billion operating revenue (2010)

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3

Kaiser Permanente Quality Improvement Journey

2005-2007

2008-2010

2011-Beyond

•Established strategic partnership

with IHI

•Develop enterprise quality strategy

•KP HealthConnect

implementation begins• Assess baseline capability

to improve

• Estalish KP’s big dots the “Big Q”

•Some best performance in KP and

high variation•Establish IHI scholarship program for

KP and safety net

• Develop Improvement Institute

•Hire master black belt mentors

•Adopt IHI’s execution model

in medical centers

• Focus on alignment,

portfolio management

achieving scale

•Deepen commitment to

analytics, evaluation and

research

• KP HealthConnect fully implemented, optimizing

•More PSO graduates than any

other organization

•Targeted participation in IHI

programming based on strategic need

• Align innovation, improvement in

key strategies

• Focus on technology integration,

informatics and improvement at

scale

• Develop deep capability at

regional levels

• Expand capability to operate as a

learning organization via

networks and KM

• 4 part series published in the Joint

Commission Journal

• KP NCQA results, Medicare Stars best

in class performance across KP

•Created Clinical Effectiveness Research

Center•Focus on total health

Our system is based on the attributes of high performing organizations

Best quality

Best service

Most affordable

Best place to

work

KP builds capability in these six areas in order to achieve breakthrough performance

© Kaiser Permanente 2010 reproduce by permission only

12/11/2012

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To

p d

ow

n

Re

du

ce

va

ria

tio

n

Learning system

• Economic and social context for change

• Models of workplace learning

• Team performance

• Define organizational needs • Create system view• Plan/ manage improvement

• Align with strategy • ID drivers and portfolios • Build capability to improve

• Engaging the hearts and minds of the front line

• Creating “line of sight” to strategic goals

• Define high performing unit-based teams

Bo

ttom

up

Le

arn

ing

an

d im

pro

ve

me

nt

High Performing Organizations Build Culture and Capability

Principles What we “do”


6

Building Will

Source: IHI 2008

Define Breakthrough

goals

Manage Local

ImprovementDevelop Capability

Spread and sustainProvide Leadership for

Large system Projects

Provide Day-to-Day

Leaders for Micro Systems

Source: IHI 2008


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Will: From Strategy to Execution

Big Aim

Strategy

Dashboard

Targets

P8P8

Inpatient Mortality: All KFH HSMR continues

below US Medicare benchmark.

HEDIS: KP performance continues to trend above the national

90th Percentile

Safety: At risk for meeting SRAE 10% reduction goal; will not achieve

RFO/VI goals

Risk Mgmt: 15% improved performance seen in 2010 was sustained in 2011

Service-METEOR: Health Care Rating: Programwide sustained gains from prior

year’s significant increase, and remains above the national 75th percentile by +3.5.

Resource Stewardship: No threshold has been established for this new top level metric,

commercial HMO risk adjusted selected services cost PMPM.

Equitable Care: The gap between the Black or African American and White

rates is 3.3 points; the disparity was 4.0 points a year ago

.

T JC: The combined TJC composite for all KFH hospitals continues to be

less than one point from 100% - the national 90th percentile Service-HCAHPS Overall Rating demonstrated a significant 3.3 point increase from the previous

year. Nurse Communication also showed a significant 2.4 point improvement from previous year.

DO NOT INCLUDE IN AUDIENCE

PACKET – FOR LIVE

PRESENTATION ONLY

12/11/2012

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9

Ideas: Manage Local Improvement

Define Breakthrough

goals

Manage Local




Provide Day-to-Day


Source: IHI 2008


10

Identifying Levers of Improvement: Driver Diagrams

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Harvesting of Ideas: Scanning

Just Do It

11

Create It

Improve It or

Adopt It

Elder

Health

Palliative Care

Program

Length of Stay

for THR

Problems Outcomes

New Model of

Elder Care

Healthy

Quality

of Life

Falls

With

Injury

Toileting &

Rounding Bundle

ID high risk from

medications

Injury-free Floors;

Delirium Prevention

No Falls

With

Injury


12

Develop Capability for Execution

Source: IHI 2008

Define Breakthrough

goals

Manage Local




Provide Day-to-Day



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Experts Operational

Leaders (Executives)

ChangeAgents

(Middle Managers, Stewards,

project leads)

Everyone

(Staff, Supervisors,

UBT lead triad)

Continuum of PI Knowledge and Skills

Deep

Knowledge

Many People Few People

Our approach will be to make sure that each group receives the knowledge and skill sets they need

when they need them and in the

appropriate amounts.

A key operating assumption of

building capacity is that different groups of people will have different levels of

need for PI knowledge and skill.

Content: What Skills Do We Need?

Shared

Knowledge


On-boarding

Develo

pan

d T

est

the S

yste

m

at

a F

acilit

y l

evel

Developing deeper capability to achieve big results over time

Exp

an

dIm

pro

vem

en

t syste

m

to a

ll f

acilit

ies

Deep

en

imp

rovem

en

t kn

ow

led

ge w

ith

in f

acilit

ies

September 2008 June 2009 2010 & 2011

Waves of Improvement Institute

Learning and sharing systems regionally and program-wide Improvement Institute

Implementation ExpansionContinuous

ImprovementComplete

Thi

s

im

We are here

Level of Project

Difficulty

• All Regions• 500 IA’s• 15 internal faculty

Mentors• 3,000+ Operations

Managers• 20,000+ Front line staff• IHI Forum and courses

• 7 regions• 300 Improvement

Advisors • 35 UBTC’s• 1,250 Operations

managers• 8,000 Front line staff• IHI Forum and courses

• 5 regions• 65 Improvement Advisors• 300 operations managers• 3,500 Front line staff• IHI Forum


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Improvement Institute

Week 1

15

SPCWeek 2

Assess, Plan

Medical

CenterResults

1,200 Graduates

$200 Million

Test, Implement

Control

90 Days: Apply Learning and Get Results

Medical

Center


Regional Case Study: Sepsis Care

Across 20 Medical Centers

Video NCAL Sepsis

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Multi-hospital Results: Reducing Mortality from Severe Sepsis

• 26% Decline in mortality

• 18% Decline in LOS

• 1,135 Lives saved

• $56MM Over-utilization avoided


Tremendous Improvement in Member Satisfaction with the Health Care they Receive

P18

Ambulatory Service Performance: CAHPS Health Care Rating

Legend:Blue = Program trend

Black = CAHPS benchmark

% o

f re

spondents

rating a

ll health c

are

in la

st y

ear

as,

9, or

10

on a

scale

of 0 to 1

0 (

from

wors

t poss

ible

to b

est

poss

ible

)

Drivers• Focus on leadership

• Alignment of goals • Engagement of front-line

Key Initiatives• Access improvement practices

• Communications

• Culture of Excellence

75th percentile

Interregional CAHPS improvement workgroup formed – sharing best internal and external practices

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Leveraging the Power of Electronic Health Records: Improved Ambulatory Care

P19

Ambulatory Performance: HEDIS Composite

(PY Year 2008)

PY = Performance Year

% o

f elig

ible

mem

bers

receiv

ing a

ppro

pri

ate

am

bula

tory

care

Drivers• Population care

• Decision support

• KP.org

Clinical Effectiveness P20

Ra

tio

of

ob

se

rve

d t

o e

xp

ec

ted

mo

rta

lity

Inpatient Outcomes: Hospital Standardized Mortality Ratios

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2008 2009 2010 2011 2012

KP - All Facilities

US Medicare Overall

Kaiser Foundation Hospital

DO NOT INCLUDE IN AUDIENCE

PACKET – FOR LIVE

PRESENTATION ONLY

12/11/2012

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Current ChallengesAlide Chase, SVP, Medicare Clinical Operations and Population Care

Medicare Care Delivery

P21

Our Big Challenges

How to provide outstanding care in both clinical quality and care experience to our Medicare members while

reducing total cost of care?

P22

Answer:• Reliably execute on proven care• Remove variation• Transform care delivery

• Design entire system to be member/patient focused

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ValuesP23

KP's commitment to high quality of care and an excellent service experience are top priorities in the organization.

This commitment remains in place and serves as a "true north" as we face significant challenges with health care reform.

The focus on patient safety, particularly in our hospitals is a key component of the plan.

All of the Medicare initiatives will result in improved quality and service with improved efficiency and effectiveness that will help make healthcare more affordable for our members.

Our National Work

Align Care to Member Needs

Engage all of Kaiser Permanente

Spread and Execution of Proven Care

Reduce Variation

Accelerate the Development Cycle

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Care Delivery Needs Differ Across SegmentsSevere Frailty/ End of Life

Healthy Chronic Conditions

Advanced Illness

Medicare

Segmentation

15 to 20%60 to 65%

10 to 15%5 to 7%

Percent of

Members

PMPM Expense

Ratio 1X 2-3X 5-8X 15-20X

Care NeedsPopulation Care Complex CareUsual Care

P25

Data Capture and Predictive Ability

SEGMENT 1:

Healthy / RobustSEGMENT 2:

Chronic Conditions

SEGMENT 3:

Advanced Illness

SEGMENT 4:

Severe Frailty /

End-of-Life

Personalizing Care through Segmentation

Moira M Belikoff | 510-267-

2976

P26

12/11/2012

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Insert Kat diagram here

Medicare Plan: Three Buckets of Work

First 5What we know

and do well

Unwarranted

Variation

Transformation

•Palliative Care

•Transitions

•Bone Health

•SNF ALF Rounding

•Clinical Onboarding

•Decrease unwarranted

admissions &

readmissions

•Decrease unwarranted

variation in services

•New provider roles

•Medical home

•Self Care

•Automation

•Care Planning

•Telemedicine

•Technology-enabled

community health

workers

+

+ Exce

llen

ce

28

P28

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29

• Most health

• Best care

• Most affordable

• Best people

Goal/Aim Primary Drivers Hypotheses - Secondary Drivers

Health

Care

People

Affordability

Act and Go Beyond

� EKG, angiography and imaging tests for low risk cardiac patients

� Antibiotics and imaging for sinusitis and headache

� Percent of women with second pap smear within 2 years, 6 months

� Redundant visits year after breast cancer is cured

� Screening PSA in men over 75 years of age

� Overly tight glucose control in some older adults with diabetes

� Using anticholinergic medications as a first line treatment of urinary

incontinence in older adults

Selected areas based on KP’s actionability and improvement of care :

Unwarranted Variation

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Transformation

Scanning Results

• We have identified promising tactics across all care delivery

domains

• No single strategy (internal or external) was both “high potential

impact” and “just spread now”

• Need to design and test our hypotheses for new operations and

workflows to achieve our goals

Innovation that Supports Transformation Now

• Hospital to Home: Identify way to move inpatient close to home

• Clinic to Home: Move ambulatory care from clinic to

“Everywhere” with telemedicine

• Integrate Complex Geriatric Care: Segment 3 & 4

Example of Programs IdentifiedAmerican

Physician House

Calls from TX

Advanced Illness

Care

Coordination-

Aetna

Grand-Aides Clinically HomePacific Group on

Health - CMS

Woodland Hills

“Geripal”

Program

Telepresence

visits in local

clinics

Healthy BonesSheffield Teaching

Hospitals

Univita HealthSILvR Network

InitiativeSeniorBridge

Ben Archer Health

Center

Pittsburgh

Regional Health

Initiative

Proactive Office

Encounter Work

Kaiser Special

Services (KSS)

Heart Failure

Transitional Care

Dementia Care

Birmingham, RAID

Community Care

of North Carolina

(CCNC)

medicare

innovations

collaborative

St. Vincent

Hospital

(indianapolis)

Beth Israel

Deaconess PACT

Providence

Portland Medical

Center

Complex Medical

Home- KPCares

Clinical Decision

Units

KPCO PATHWAAY

for Seniors.

Transforming

Community

Service

Nurses Improving

Care for

Healthsystem

Elders

Six Features of

effective

coordinated care

Care of the

Elderly, England

CareFirst

BlueCross Care

and Cost

Improvement

UCLA Alzheimers

and dementia care

Guided Care

ProgramPE 65

“One Stop Shop”

for Palliative Care

Primary Care and

Public Health

GRACE Team Care

(Indiana

University)

Janus Health Med StatU. of Missouri

LIGHT^2 - CMS

St. Francis

Healthcare Hawaii

Assisted Living

Facility ProgramAICC Pilot

San Rafael

Delerium

Management

Initiative

Stanford AICU

Teaching Geriatric

Skills to

Hospitalists

Council of Aging

of Southwestern

Ohio

Ocean Medical -

Advanced Care

Elderly

Developmental

Disabilities Health

Sanford Health

integrated primary

care

DriveABLE Geriatric EDPioneernetwork.n

etCapital Health Plan

Housecall

Providers, Inc.( in

Portland)

Erie St. ClairCareSouth

Carolina

Emory Critical Care

- CMS

Sutter Advanced

Illness

Management

(AIM)

Relay for Life

Advance Care

Planning

Respecting

Choices®

INTERACTBrooklyn House

Calls

Dementia Care

"Aging Brain

Care" Indiana U

UPENN

transitional care

model

Northwest

Advancing Quality

Alliance

Innovative

Oncology Business

Solutions

Indiana University

Community Rx

System

Memory Clinics Wellness ClinicsAcute Care for

EldersVitality 360

Hospital at Home

- Presbyterian Care Transitions Hospital at Home

CAPABLE for frail

dually eligible-

Johns Hopkins

University

Emergency

Medical Services

Home Visits Elder Care Clinic HELP (Yale)

Novant Health -

private duty

nursing

ACP Pilot in Palo

Alta

Janssen

Connected Care

Challenge

Finalists

Population Care

Management

Delirium detection

and prevention -

Methodist

Vanderbilt med

center - CMS

Palliative Care

Stand Alone

Clinics

Virtual Specialist PACE UCLA Scribing

P32

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KP

Care Settings

Technology Enabled

Care Settings

Community

Care Settings

Acute, Urgent & Emergent Care Encounters

Ambulatory Care Encounters

Population Care Encounters

Transformation SpacesHigh potential / high value tactics – We can improve care across our entire landscape of settings

and strategies – to provide the right care at the right time in the right place.

Geriatric

ED

Telemedicine

Monitoring

Telemedicine

Remote

Monitoring

Self Care

Mobile Apps

Self Care

Mobile Apps

Grand

Aides

Promatores

Hospital & ED

Clinic

Home

Everywhere

Call Centers / KP.OrgCare / Case

Management

Automated

Care Mgt

Continuum of Care

Neighborhoods

Social Networking

Internet Care

Communities

Internet Care

Communities

Care

Transitions

Bone Health

Palliative

Care

Assisted LivingAssisted Living

RoundingWellness

ClinicsGeriatricGeriatric

Specialty

Clinics

Geriatric

Med Home

SNF / ALF

HH

Internal

Self ServiceSelf Service

KP.org

Hosp at

HomeVirtual

Wards

Onboarding

Clinical

Onboarding

Primary Care

Home Visits

Primary Care

Home Visits

Naturally

Communities

Naturally

Occurring

Retirement

Communities

Neighborhood

Centers

Neighborhood

Health

Centers

P33

External

34Initial Demonstrations

Hospital to Home Clinic to Home Integrate Complex

Geriatric Ambulatory

Care

� Develop ways to move

inpatient care closer to

home

� Hospital to Home, Virtual

Wards

� Using telemedicine to

move ambulatory care

from the clinic to

“everywhere”

� Virtual visits,

Telemedicine, Remote

monitoring

� Address the clinical needs and

operations to support service

delivery for complex

members across the

continuum; clinic to home to

community

� Matching care to need: Think

through how operations for

the complex “micro-panel”

will integrate with the

“macro-panel” to achieve

greater affordability

• Shorten text here – get from Jann – Annie to write

KPPG Expectations: Each Participating Region and Demonstration Will:

• Designate a Health Plan and Medical Group executive who will be accountable for the Demonstration outcomes

• Define specific affordability hypotheses that can be quantified

• Set targets and define metric indicators for contributions to affordability, quality, and experience for the

Demonstration model, the region and KP-wide, by June 1, 2013

• Show your Demonstration is on a trajectory to hit your end-of-year Demonstration targets by June 1, 2013.

Show your Demonstration is on a trajectory to hit your regional targets by December 31, 2013

• Be prepared to share learning and progress toward objectives on a quarterly basis beginning in December 2012

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MEDICARE CARE DELIVERY STRATEGY

E4 = LEARNING + ACCELERATION

35

• Clinical Disciplines

• Business Disciplines

• Internal KP Accelerators

• Segmentation

• First 5

• Variation

• Demonstrations

• Technology

• Nursing, Pharmacy, P&S, etc

• Internal Communications

• External Communications

• CMS Advocacy

• Publication

• External Relationships

• Scanning

• Strategic Planning

• Opportunity Analysis

• Generative Events

• Leadership Dashboard ENVISION

Explore what’s possible?

Create roadmap amidst the

possibilities

EXCITE

Activate the organization

Articulate vision and how we are getting there

solve and plan execution

ENGAGE

Develop key partners

Create opportunities to problem solve and plan execution

EEXECUTE

Test hypotheses,

identify what works, and go

to scale

Member Voice

And

Experience

Engage the Whole Organization

Jann’s star clusters here

Quality and Innovation Centers: Kaiser...

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